Provider Demographics
NPI:1528583846
Name:LARSON, ANNETTE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 44TH AVE S STE E
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3434
Mailing Address - Country:US
Mailing Address - Phone:701-787-5800
Mailing Address - Fax:701-787-5802
Practice Address - Street 1:1451 44TH AVE S STE E
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3434
Practice Address - Country:US
Practice Address - Phone:701-787-5800
Practice Address - Fax:701-787-5802
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12482363A00000X
NDPAC0723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant